| NPI | 1972929560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO DEN.00204245) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D008771) |
| Enumeration Date | 2014-03-06 |
| Last Update Date | 2021-04-13 |